Lumbar Injections For Diagnosis and Treatmentneurosurgerylnh.com/uploads/Lumbar Radicular Pain Karachi 2017.pdf · Lumbar Injections For Diagnosis and Treatment Ovidiu Nicolae Palea

1/10/2018

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www.centrul-provita.ro

Lumbar Injections ForDiagnosis and Treatment

Ovidiu Nicolae PaleaCentrul de Diagnostic si Tratament ProVita


Pain Management

Anesthesiology and Intensive Care

2009 decided to focus on Pain Management

2010 started the first Multidisciplinary Minimal Invasive Pain Center in Romania –Centrul de Diagnostic si Tratament Provita

Full time Pain Management

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Pain Management

Medicine has evolved into 30 specialties and OVER 140 Subspecialties!!!!!

Anesthesiologists were first, but now ….

Neurosurgeons

Physical Medicine and Rehab docs

Rheumatologists

Orthopedic Surgeons

Neurologists

Interventional Radiologists


Pain Management

Patient Population – sub acute and chronic:

Lower back 50%

Upper back 20%

Peripheral joints – hip, knees etc – 20%

Head and Facial Pain 10%

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The Goal Today:

Functional Diagnosis

Radiological Landmarks

Technique for Infiltrations


Definition and Etiology

Radicular pain is a type of pain that radiates into the lower extremity directly along the course of a spinal nerve root

It needs a good differential to Pseudoradicular Pain

Radicular pain is caused by inflammation rather than compression, and/or injury to a spinal nerve root

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Inflammation of the nerve root can be caused by:

‐ herniated disc

‐ facet hypertrophy

‐osteophytes

‐epidural fibrosis



Inflammation of the nerve root can be caused by:

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Inflammation of the nerve root:


Clinical Diagnosis

History of Present Illness

‐ how did the pain start?

‐ where is the pain? Back or leg pain?

Physical exam:

‐ neurological deficits

‐ straight leg raising, SI and Hip

‐ reflexes

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Differential Diagnosis

Facet pain

Sacroiliac pain

Coxarthritis

Tendinopathy

Peripheral nerve Entrapments

Bursitis, Psoas Impingement

Internal pathology


Radiological Diagnosis

X ray AP and Lateral

‐ mainly bone landmarks BUT also critical alignment information

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CT scan

‐ more soft tissue anatomy

‐ great for osteophytes

‐ used mainly when MRI is contraindicated



MRI

‐ soft tissue detailed anatomy

‐ very limited for osteophytes

‐ BIGGEST pitfall: NO CLINICAL CORELLATION!!!

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Clinical Diagnosis is Critical

Do we treat the actual hernia?

Do we treat the cause? Is Hernia the cause?

Do we treat the SYMPTOMS?

Symptoms caused by what? Hernia?

Nerve Inflammation?

Fibroses of the nerve root?


Electromiography

Great Sensitivity

Poor Specificity

Poor clinical correlation

Lesion has to be over 4 weeks old to see any changes

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Functional Diagnosis is Critical

Guided Anesthetic infiltrations are the only available functional diagnosis at the present time ‐

In multilevel pathology there is no other test that has a better correlation!!!!!


Functional Diagnosis is Critical

Guided Anesthetic infiltrations are the only available functional diagnosis at the present time – X ray guided or Ultrasound guided

Ultrasound guided injections are growing as indications more and more – axial as well as articular or peripheral nerve entrapments

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Indications for minimal invasive

Symptoms severity VAS >4‐5/10

Duration of pain – usually > 2 weeks

Failed conservative treatments – kinetotherapy, NSAIDS


NOT AN INDICATION FOR ANYTHING!!

Numbness, hypoesthesia

Old moderate motor deficits

Presence of a hernia on the MRI but no symptoms

Clinical picture improving!!!

Free fragments

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Epidural Injections

There 3 types:

‐ Interlaminar Epidural

‐ Caudal Epidural

‐ Transforaminal Epidural


Interlaminar Epidural Steroid injection

34% Success rate

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Interlaminar Epidural Steroid injection

Nonspecific block

No diagnostic value


Caudal Epidural

60% success

Nonspecific

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Caudal Epidural

60% success


Transforaminal Steroid Injections

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Transforaminal Infiltrations



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Transforaminal Injections

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Transforaminal Steroid Injections


Often first step

Risk of:

Bleeding

Infection

Nerve damage

Wet tap

Paralysis

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Often first step


Treatment Algorythm

First step is always GUIDED periradicular injections!

‐ success rate of 70‐80% for radicular pain that isunder 8 weeks old!!

‐ response is due to the long acting depo steroidinjection and is based on the assumption that most ofthe pain is due to inflammation

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Treatment Algorythm

First step is always GUIDED periradicular injections!

‐ response is MAINLY in the second week after the injection NOT at the time of the infiltration

‐ it can be repeated x3 at 2‐4 weeks interval if RESPONSE is achieved


Technique – we love our Scotty Dog

Discography

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Discography



Discography

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Facet Injections



Facet Injections

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Facet Injections


Treatment Algorythm

Epiduroscopy with laser ablation of scar tissue

small hernias

multilevel degenerative spine

moderate spinal stenosis

failed back surgery

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Treatment Algorythm



Treatment Algorythm


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Cadaver Workshops for guided infiltrations

‐ Pick up initially easy cases –lumbar single hernia‐ Pair up with a radiologist ‐ Start with Caudal Ultrasound guided

‐ do CT guided infiltrationsAsk for help any time!!!

How to start my practice?


‐ Anesthesiologists can DIAGNOSE the cause of pain!!!

‐ We can treat the cause of pain

‐ You could be the third opinion

TAKE HOME MESSAGE

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www.centrul-provita.roMy email: [email protected]

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Documents

Lumbar Injections For Diagnosis and Treatmentneurosurgerylnh.com/uploads/Lumbar Radicular Pain Karachi 2017.pdf · Lumbar Injections For Diagnosis and Treatment Ovidiu Nicolae Palea